Meningovascular Neurosyphilis Presenting as Multifocal Stroke: A Case Report and Literature Review

TL;DR

A case of meningovascular neurosyphilis mimicking stroke is reported, highlighting the importance of early diagnosis and treatment for neurological recovery.

Contribution

This case report adds to the understanding of atypical neurosyphilis presentations and emphasizes the need for comprehensive diagnostic approaches.

Findings

A 38-year-old patient with stroke-like symptoms was diagnosed with meningovascular neurosyphilis after MRI and serological testing.

Treatment with intravenous penicillin G led to significant cognitive and functional recovery in the patient.

A negative CSF VDRL test does not rule out meningovascular neurosyphilis; combined clinical and radiologic evidence is crucial.

Abstract

Neurosyphilis (NS) remains a diagnostic challenge due to its diverse clinical manifestations and its ability to mimic other neurological disorders. Despite the global decline in syphilis incidence during the antibiotic era, a recent resurgence has led to an increase in atypical and meningovascular presentations. Early diagnosis is critical, as timely treatment can prevent irreversible neurological damage. We report the case of a 38-year-old immunocompetent male who presented with acute vertigo, unsteady gait, and subsequent confusion. Initial imaging and laboratory investigations were unremarkable; however, MRI revealed multifocal ischemic lesions. Serological testing demonstrated high-titer Treponema pallidum antibodies (rapid plasma reagin 1:256), while CSF analysis showed lymphocytic pleocytosis, elevated protein, and an increased IgG index, with a negative CSF VDRL. The diagnosis of meningovascular NS (MVS) was established. The patient received intravenous penicillin G for three weeks, resulting in gradual cognitive and functional recovery. After rehabilitation, his Functional Independence Measure score improved from 83 to 121, and his Mini-Mental State Examination score improved from 9 to 21. MVS should be considered in patients presenting with stroke-like symptoms, particularly when conventional vascular risk factors are absent. A negative CSF VDRL does not exclude the diagnosis; combined clinical, serologic, and radiologic evidence is essential. Early recognition and appropriate antibiotic therapy can lead to significant neurological recovery.

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